16 November 2007

The Agency first highlighted the issue of patient deterioration in July this year with its report Safer care for the acutely ill patient: learning from serious incidents which included a detailed analysis of 576 deaths reported to the Agency’s National Reporting and Learning System (NRLS) over a one year period.

More than 11 per cent of these deaths related to patient deterioration not recognised or not acted upon and the NPSA pledged to carry out further work to explore the issue and identify contributing factors.

This new report should also be used in tandem with the National Institute for Health and Clinical Excellence (NICE) guideline on recognition and response to acute illness in hospitalised adults, launched in July.

Dr Kevin Cleary, Medical Director at the National Patient Safety Agency, said: “Patients should be able to feel confident that should their condition deteriorate in hospital, they are in the best place for prompt and effective treatment.

"However patients who are, or become, acutely unwell may not receive the best care because their deterioration is not recognised or might not be acted upon sufficiently quickly.

"Whilst the issue of deterioration is well recognised we felt it important to gain a better understanding of why these incidents occur. This report sets out why deterioration incidents happen and helps NHS staff working in acute hospitals to improve patient safety in this area in a very practical way. It includes a checklist of questions, a toolkit, links to a variety of resources and good practice examples, to help guide local action."

Andrew Dillon, Chief Executive of NICE said: "We welcome this report as a further contribution to improving patient care in this area. The NICE guideline published in July 2007, offers advice on the care of adult patients who are or become acutely while in hospital, and advises how serious problems can be avoided. I hope that NHS staff will use this report and the NICE guideline to significantly improve the care and safety of acutely ill patients. “

The study found that common factors contributing to deterioration incidents include:

Not taking observations

Not recognising early signs of deterioration

Not communicating observations that cause concern

Challenges in prioritising competing demands

Verbal and written communication breakdown

Insufficient training to understand the relevance of observations

A lack of successful implementation of relevant policies and procedures

A lack of strong and effective ward leadership.

The NPSA is recommending that every acute trust sets up a multidisciplinary ‘deterioration recognition group’ to lead and coordinate efforts to improve the safety of patients who are vulnerable to deterioration. These groups should lead on reviewing local systems and processes and coordinating efforts to ensure optimum patient safety.

The NICE guideline, Acutely ill patients in hospital: Recognition of and response to, acute illness in hospitalised adults, can be found at http://www.nice.org.uk/CG50

The National Patient Safety Agency (NPSA) helps the NHS learn from its mistakes so that it can improve patient safety. It does this by collecting reports on errors and other things that go wrong in healthcare via its National Reporting and Learning System (NRLS) so that it can recognise national trends and introduce practical ways of preventing problems. It does not investigate individual cases or complaints, but it does listen to public concerns and uses what it learns to improve safety.